Documentation, Recordkeeping, and Patient Rights
What the exam tests
This domain tests record content, retention, release of information, and patient rights. Questions often ask what must be in the plan of care or whether a record can be changed.
Core rules
- The initial evaluation must document history, examination findings, PT diagnosis, prognosis, goals, and the plan of care.
- The plan of care must include measurable goals, interventions, frequency and duration, and discharge criteria. It should be reviewed and updated as the patient’s condition changes.
- Entries must be dated, authenticated, and legible. Late entries should be labeled as late, not backdated. Corrections should preserve the original entry.
- Retain records for at least seven years after the last treatment, and longer for minors as required by Board rule. Keep records secure and confidential.
- Patients have rights to privacy, informed consent, access to their records, and respectful care. Release of protected health information requires a valid authorization unless a legal exception applies.
- Document patient education, refusal of care, and communication with other providers.
Worked example
A patient requests a copy of their record. The clinic may provide a copy and charge a permitted fee, but it should not alter the record or release it to an employer without authorization. If the patient asks to change a statement they disagree with, the clinic can add a patient amendment or statement rather than rewriting history.
Traps
Backdating a note; writing “patient improved” without objective data; releasing records to a spouse without authorization; failing to document a refused treatment; destroying records too early.